Nursing 202

• 1) manubrium
• 2) body
• 3) xiphoid process

suprasternal notch

• - bony ridge (articulation of manubrium and body of sternum)
• - Continuous with 2nd rib (count rib and ICS from this point)- ICS numbered by rib above
• - site of tracheal bifurcation into right and left main bronchi
• - corresponds with upper border of atria

1. 12 ribs

• 2. Costochondral junction: where rib attaches to cartilage
• intercostal spaces: below each rib
• floating ribs (11-12)- attached to spinal column only; 12th rib tip palpable midway between spine and side [11 is on side and 12 is more posterior]

• normal: < or equal to 90 degrees
• abnormal: (angle increases [flattens] with hyperinflation)- e.g. emphysema

• C7
• - palpate with head flexed
• - if 2 bumps (then C7 & T1)

• 12
• - spinous process (knobs on vertebrae)- some palpable

lower tip (inferior border) at 7th-8th rib

reference lines: verticle lines used to document physical findings

• Anterior:
• - midsternal
• - midclavicular (MCL)
• Posterior:
• - vertebral (midspinal)
• - scapular
• Lateral:
• - Anterior axillary line (AAL)- at anterior axillary fold
• - Midaxillary line (MAL)- midway between AAL and PAL
• - Posterior axillary line (PAL)

• 1. suprclavicular (above clavicle)
• 2. infraclavicular (below clavicle)
• 3. infrascapular (below tip of scapula)

• 1. Mediastinum (heart and great vessels, esophagus, trachea)
• 2. Pleural Cavities (contains lungs)
• 3. Diaphragm (floor of thorax; major muscle of respiration)

• Anterior
• - Apex (3-4 cm above 1st rib)-top
• - base (rests on diaphragm)- bottom
• - right side (at 5th ICS, MCL)
• - Lt side (at 6th ICS, MCL)

• Lateral
• - from apex to axilla to 7th-8th ribs

• Posterior
• - (C7 to T10 [or T12 with inspiration])
• - upper lobes T1 to T3/T4
• - lower lobes T3 to T10 (expiration) or T12 (inspiration)

Right (3 lobes: upper/middle/lower)- shorter due to liver

Left (2 lobes: upper/lower)- narrower due to heart border

• 1. Horizontal Fissure (right side only)- 4th rib right sternal border to 5th rib MAL
• - separates upper and middle lobe

• 2. Anterior Oblique Fissures (bilateral)- 5th rib MAL to 6th rib MCL
• - right (separates middle and lower lobes)
• - left (separates upper and lower lobes)

• Visceral (lines lung surface)
• Parietal (lines chest wall and diaphragm)

• Pleural Cavity (negative pressure holds lungs against chest wall)
• Costodiaphragmatic recess (pleura extend 3 cm below level of lung)- potential space for fluid/air which may compress lung

• - trachea anterior to esophagus
• - starts at cricoid (10-11 cm long)
• - bifurcates at manubriosternal angle (anteriorly)
• - bifurcates at T4 (posteriorly)

• - right main stem bronchus (shorter and straighter)- increased risk of aspiration
• - dead space (trachea and bronchi)- filled with air, but no gas exchange
• - bronchial tree lines with goblet cells (secret mucus that entrap particles) and cilia (sweep particles upward); smoking paralyzes the cilia and results in mucus pooling
• - acinus (functional respiratory unit)- bronchioles, alveolar ducts, alveolar sacs and alveoli
• - alveoli (300 million)

• 1. supplies O2 and eliminates CO2
• - respiratory acidosis: retained CO2
• - respiratory alkalosis: excessive excretion of C)2 through respirations
• 2. helps maintain acid-base balance
• - Respiratory center (brain stem)-pons and medulla
• - increased CO2 is normal stimulus to breathe
• - chronic hypoxia desensitizes CO2 receptors in the brain; thus
• low O2 levels become the stimulus to breathe (delivery of high
• O2 concentrations may result in apnea)

• 1. Cough (timing)
• 2. Cough (character)
• 3. Sputum (amount, color, odor)
• 4. Shortness of Breath and Dyspnea (difficult, labored breathing)
• 5. Past history
• 6. Miscellaneous symptoms
• 7. Smoking history (cigarettes, cigars, pipes, marijuana)
• 8. Family History (allergies, asthma, TB, cystic fibrosis, lung cancer, emphysema, etc.)
• 9. Environmental Exposure (use of protective masks?)
• 10. Health Promotion (PPD, influenza immunization, pneumococcal vaccine)

• - Continuous- respiratory infection
• - Nighttime, when recumbent (post nasal drip; sinusitis, GERD)
• - morning, upon awakening (chronic bronchitis, "smokers cough")
• - specific setting (allergies)

• - hacking (mycoplasm pneumonia)
• - dry, non productive (early CHF, allergies, meds [acei])
• - barking (croup)
• - congested (bronchitis, pneumonia)

• 1. Clear/white (viral bronchitis/pneumonia)
• 2. Translucent white/gray (noninfectious, chronic bronchitis, smoker)
• 3. Rust (pneumococcal pneumonia)- blood mixed with yellow sputum
• 4. Green/yellow (bacterial bronchitis/pneumonia)
• 5. Pink: frothy (pulmonary edema)
• 6. Blood (hemoptysis)- cancer, TB
• 7. Foul odor (bacterial)

• - Orthopnea: (difficult breathing supine- 2 pillow, etc.)- heart failure
• - paroxysmal nocturnal dyspnea (PND)- awakens from sleep with SOB (heart failure)
• - DOE (dyspnea on exertion)

• - lung disease, COPD, asthma, cystic fibrosis, etc.
• - allergies (dust, pollen, animals, mold)

• 1. Diaphoresis (night sweats) TB, HIV, other infection
• 2. Fever, chills, sweats (f/c/s)- infection
• 3. Unintentional weight loss- cancer
• 4. Dependent edema, PND, orthopnea- heart failure
• 5. Confusion, restlessness- hypoxia
• 6. Pleurisy (chest pain with breathing)- inflammation of pleura

• 1. Grain/pesticide inhalation (farmers)
• 2. Histoplasmosis (inhaled fungus)- midwest
• 3. Coccidioidomycosis or "Valley fever" (inhaled fungus)- San Joaquin Valley [Bakersfield area]
• 4. Pneumoconiosis (coal miners)
• 5. Silicosis (stone cutters, miners, potters)
• 6. Asbestos (plumbers)- abestos exposure + smoking increases lung CA risk (more than 10x)

• - URIs (4-6/year = normal) compared to adults (2-4/yr)
• - Asthma- may outgrow as bronchial tubes enlarge
• - accidental aspiration- child proof the home

• - SOB/ fatigue with daily activities (decreased vital capacity [exhaled air after maximum inspiration] as measured by spirometry)
• - lung disease
• - chest pain with breathing (rib factures-spontaneous or r/t trauma/abuse/falls)

• 1. Respiratory rate, rhythm, effort
• 2. Normal shape and symmetry of chest wall (AP diameter< transverse; 1:2 to 5:7 [increases with age])
• 3. Spine (assess for abnormal curvatures; may impair cardiopulmonary function)
• - Scoliosis (lateral curve)- entire spine affected
• - more common in girls, adolescents
• - assess uneven shoulder, scapular, hip heights
• - observe gait
• - severe curvature (>45)- may decrease lung volumes
• - Kyphosis (hump back)- T-spine
• - Lordosis (sway back)- L-spine
• - body position
• - Relaxed
• - Professional or tripod position (abnormal)- aids in expiration

• - Palpate entire chest wall (tenderness lumps, masses)
• - Symmetric chest expansion (at level T9 or T10) may be uneven with atelectasis, pneumothorax, pleural effusion, phrenic nerve damage, etc.
• - tactile fremitus (vocal fremitus)- repeat "99"
• - palpable vibrations (use base of fingers at MCP joint or ulnar surface) - should be felt
• - start at lung apices (symmetry is most important)
• - most prominent between scapulae and sternum; progressively decreases down thorax
• - greater in thin persons (due to decreased thickness of chest wall)
• - Increased fremitus
• - consolidation extending to lung surface (pneumonia)
• - decreased Fremitus (transmission of vibration blocked)
• - bronchial obstruction
• - pneumothorax
• - Pleural effusion
• - COPD (emphysema)
• - Crepitus (sub-q emphysema)
• - course cracking sensation
• - R/T air entering sub-q tissue (open thoracic injury, chest surgery, tracheostomy)

• - percuss ICS
• - start at aspices (above clavicle) and percuss side-to-side down back
• - avoid scapula and ribs

• Resonant: normal
• Hyperresonant: emphysema, pneumothorax
• Dull: increased density- atelectasis, pneumonia, pleural effusion

kidney infection

• - from C7 to T10
• 1) Lean forward; breathe deeply through mouth (hug chest to open interspaces)
• 2) Use diaphragm of stethoscope (assess symmetry and don't forget lateral lung fields)
• 3) Progress from top to bottom and side to side; listen at each location; listen at each location for a full respiratory cycle (inspiration and expiration)

• 1. Bronchial
• - loud, harsh
• - norm over neck (trachea and larynx)
• - ABN if heard over peripheral lung fields (indicates consolidation)
• 2. Bronchovesicular
• - moderately loud/harsh
• - norm over midsternum and between scapula in back (major bronchi)
• 3. Vesicular
• - low, soft
• - norm over peripheral lung fields
• - absent (mucus plug, collapsed lung)- report immediately!

• - added sounds not normally present
• - rhonchi, crackles

• rhonchi: clear with coughing and crackles do not
• - rhonchi are deeper, more prolonged, more rumbling, more pronounced during expiration

• - sounds like a velcro opening
• - produced when there is fluid inside a bronchus causing a collapse of distal (smaller) airways and aveoli. Crackles occur when there is sudden equalization of pressure causing some of the airways to pop open.
• - Heard on inspiration; doesn't clear with coughing
• - causes (atelectasis, pneumonia, fibrosis, heart failure, pulmonary edema)
• fine crackles: (high pitched, short duration, cracking and popping sounds)
• coarse crackles (low-pitched, longer duration, bubbling and gurgling sounds)

• - airflow through airway obstructed by thick secretions, spasm, or tumor (bronchitis, decreased cough reflex, etc.)
• - loud, low, coarse sounds (like a snore or rumble) most often heard continuously during inspiration or expiration
• - often clears with coughing or suctioning

• - airflow through a constricted airway (bronchospasm associated with asthma; acute or chronic bronchitis)
• - high-pitched sqeaking sound (like a whistle)
• - primarily heard on expiration, but, may also be heard on inspiration
• - assess breath sounds with forced expiration in an asthma patient to check for bronchoconstriction.

• - a sign of respiratory distress
• - r/t partial airway obstruction (foreign body)
• - louder in the neck than chest

• - caused by inflammation of pleural surfaces (pleurisy)
• - coarse, rubbing or grating sound during inspiration or expiration (disappears with breath holding)

• Bronchophony (repeat "99" or "blue moon")
• - Norm ("99" muffled and indistinct)
• - ABN (clear "99)- increased lung density
• Egophony (repeat "E")
• - Norm ("eee" sound)
• - ABN ("E" to "A" changes)- consolidation
• Whispered pectoriloquy (whisper 1-2-3)
• - Norm (sounds faint, muffled, almost inaudible)
• - ABN (sounds clear and distinct)- consolidation

• 1. Skin (pallor, cyanosis)
• 2. Nails (clubbing)- r/t chronic fibrotic lung changes
• 3. Pursed lips (seen in obstructive disease)- prolongs expiration to allow for exhalation of trapped air
• 4. Splinting- shallow breaths to control pain
• 5. quality of respirations (quiet, easy and non labored)
• 6. Tracheal Position
• - tension pneumothorax-trachea shifts (called tracheal tug) to the opposite
• side of lung collapse
• 7. Chest
• 8. Costal angle < 90 degrees (barrel chest >90)
• 9. LOC (drowsiness r/t cerebral hypoxia)
• 10. Retraction or bulging of ICS- unilateral vs bilateral
• - retraction (obstruction or increased respiratory effort)
• - bulging (trapped air-emphysema)- causes barrel chest
• 11. Use of accessory neck muscles to lift sternum and rib cage (SCM, scaleni [below SCM] and trapezius; neck muscles may be overdeveloped with chronic respiratory disease)
• 12. Respiratory Rate and Patterns

• 1. pectus excavatum: sunken sternum, funnel chest
• 2. pectus carinatum: forward protrusion, pigeon chest
• 3. barrel chest (increased AP diameter)- associated with aging, emphysema, asthma

Retraction: (obstruction or increased respiratory effort)

Bulging: (trapped air-emphysema)-causes barrel chest

• 1. tachypnea (rapid, shallow breathing; >20/min)- fear, fever, anxiety, exercise, respiratory insufficiency, pneumonia, alkalosis, pleurisy, lesions in the pons.
• 2. hyperventilation (rapid, deep breathing)- extreme exertion, fear, anxiety, diabetic ketoacidosis (DKA)
• - CO2 is excreted thru respirations (thus increasing the alkalinity of the
• blood)
• 3. bradypnea: (regular, slow breathing; <10/min) -depressant drugs, increased intracranial pressure (ICP), diabetic coma
• 4. hypoventilation: (irregular, shallow)- narcotic OD, anesthetics, prolonged bedrest, splinting with pain.
• - CO2 is retained (may cause acidosis)
• 5. Cheyne-stokes (regular, cyclic; breathe 30-40 sec, then apnea x 20 sec)- CHF and other causes
• 6. biots (ataxic)- irregular, deep, slow with periods of apnea (precedes Cheyne Stokes)
• 7. Stertorous: snoring
• 8. Stridor: croup, foreign body, growth on vocal cords, high pitched on inspiration

• - symmetric chest expansion (thumbs on xyphoid process)
• - tactile fremitus (chest wall vibrations while repeating "99")- start at apices and work down; avoid breast tissue
• - palpate anterior chest wall (tenderness, lumps, masses)

• - start at apices
• - percuss interspaces for resonance
• - compare sides
• - avoid breasts
• - note cardiac dullness
• - border of liver (dullness at 5th ICS MCL)
• - gastric bubble on left (tympanic)

• - start at supraclavicular space and progress down to 6th rib
• - follow same pattern as with percussion

collapsed alveoli; predisposes to pneumonia

inflammation of bronchi-acute or chronic

destruction of alveoli; decreased gas exchange

intermittent bronchospasm/constriction- may lead to chronic lung disease

fluid in pleural space

air in pleural space; collapsed lung

blood in pleural space

• - count RR for 60 seconds
• - less than or equal to three months old (obligatory nose breathers)- nasal obstruction can cause death
• - less than or equal to 5-6 yo (bronchovesicular breath sounds normal in peripheral lung fields)